Ishcemic and hemorrhagic stroke, a light on integrated approach

Ishcemic and Ishcemic and Hemorrhagic stroke - A Hemorrhagic stroke - A

light on Integrated light on Integrated approachapproach

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Dr Jayagovinda UkkinadkaDr Jayagovinda Ukkinadka

““Ukkinadkas Ayurveda”Ukkinadkas Ayurveda”

Stroke

Stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurological function.

Stroke is a nonspecific term encompassing a heterogeneous group of pathophysiologic causes.

In Ayurveda, in Simple words Samanavritha Vyanavayu

Stroke can be explained as Samanavritha Vyanavayu.

Here The brain centers responsible for body movement (regulated by vyanavayu) is affected by obstructed peripheral blood circulation (regulated by Smanavayu)

Various etiological factors which in turn produces Srothorodha or Srothobheda (in Murdhni) causes this condition.

Consider Avarana of other vatha factors also

Samana vayu Avarana of Prana vayu, Udana vayu and Apana vayu should also be considered depending upon the signs and symptoms involved.

Samanavritha Vyanavayu Lakshana And Chikitsa

• Murcha, Tandra, Pralapa, Angasada, Agni, Oja and Bala kshaya.

• Treatment is Vyayama and Laghu bhojana along with other Vathavyadhi chikitsa.

• Also consider chikitsa of Avaraka followed by Avritha depending upon the pathophysiology.

Ishchemic & Hemorhagic stroke

Broadly stroke is classified into two. Ischemic & Hemorhagic

Ischemic stroke- 3 major types

Large artery infarction Small-vessel, or lacunar infarction Cardioembolic infarction

Others are Thrombotic stroke Water shed infarcts

Non modifiable Risk factors

Age Race Sex History of migraine headaches Sickle cell disease Fibromuscular dysplasia Heredity

Modifiable risk factors Hypertension (the most important) Diabetes mellitus Cardiac disease Hypercholesterolemia Transient ischemic attacks (TIAs) Carotid stenosis Hyper homocystinemia Lifestyle issues - Excessive alcohol intake, tobacco use,

illicit drug use, obesity, physical inactivity Oral contraceptive use

ACA-MCA-PCA territory

Large artery infarct-MCA left side

Middle cerebral artery stroke

Contralateral hemiparesis & hypesthesia, Ipsilateral hemianopia, & gaze preference

toward the side of the lesion. Agnosia is common (sensory damage) Aphasia - if the lesion occurs in the dominant

hemisphere. Since the MCA supplies the upper extremity

motor strip, weakness of the arm and face is usually worse than that of the lower limb.

Anterior cerebral artery stroke

ACA occlusions primarily affect frontal lobe function

can result in disinhibition and speech perseveration, producing primitive reflexes (eg, grasping, sucking reflexes)

altered mental status, impaired judgment contralateral weakness (greater in legs

than arms), contralateral cortical sensory deficits gait apraxia, and urinary incontinence.

Posterior cerebral artery stroke

Affect vision and thought producing contralateral homonymous

hemianopia, cortical blindness, visual agnosia, altered mental status, and impaired memory.

Other features include

Posterior cerebral artery stroke Vertigo Nystagmus Diplopia Visual field deficits Dysphagia Dysarthria Facial hypesthesia Syncope Ataxia

MCA and ACA infarct with petechial hemorhage

Internal Carotid artery occlusion

Lacunar infarct – in CT and MRI

Infarct diameter less than 1.5 cm Due to occlusion in circle of willis either in MCA

or ACA territory

Internal capsule - thalamus

1, Insula. 2, Internal capsule. 3, Caudate nucleus. 4, Putamen. 5, Posterior limb, internal capsule. 6, Splenium, corpus callosum.7, Thalamus.

Investigation modalities

CBC Blood Chemical analysis CT scan MRI MRA ECG, Echo cardiography etc as

necessary

ISCHEMIC CORE

An acute vascular occlusion produces heterogeneous regions of ischemia in the affected vascular territory. The quantity of local blood flow is made up of any residual flow in the major arterial source and the collateral supply, if any.

Regions of the brain with CBF lower than 10 mL/100g of tissue/min are referred to collectively as the core, and these cells are presumed to die within minutes of stroke onset.

PENUMBRA

Zones of decreased or marginal perfusion (CBF < 25 mL/100g of tissue/min) are collectively called the ischemic penumbra. Tissue in the penumbra can remain viable for several hours because of marginal tissue perfusion.

Saving Penumbra

In Acute ischemic stroke the current modern approach is to save and to convert penumbra to normal tissues as much as possible

Thrombolytic therapy is the recent addition, others are use of antiplatelet and anti coagulant drugs to prevent the recurrence of stroke.

The main aim of the medication in modern medicine are

Thrombolytic-alteplase (rt-PA) Reperfusion-recanalisation Antiplatelet- Clopidogrel, aspirin Anticoagulants-warfarin etc- usually in

thromboembolic stroke Neuroprotective- citicoline, vitamins etc Symptomatic management

Major drugs used in modern medicine

Thrombolytic Antiplatelet and anti coagulants Antipyretic drugs Anti hypertensives Diuretics to reduce cerebral edema Anti epileptics in case of seizure And all symptomatic approach to handle the

different situation

Management of Hypertension in Ischemic stroke

Sudden bringing down of blood pressure is not recommended in ischemic stroke

BP <200/120 should not be managed aggressively and should wait for spontaneous recovery. But BP above this should be treated but care should be taken so that sudden fall in BP should be avoided to prevent fall in blood perfusion

Main aim of Treatment in UA Reperfusion- Theekshna Nasya (TN) Antiplatelet- Cholestonorm Capsule Neuroprotective- Herbal preparations Protecting vitals-symptomatic management Encouraging Neuroplasticity- by1. TN, Irritant Lepas, Pindasweda,

Physiotherapy & Accupunture 2. Internal medicines to encourage possible

regeneration

Theekshna Nasya (TN)

TN is the 1st treatment to be considered in Management of Acute CVA. But should be very cautious before administration.

This simultaneously treats Avaraka and Avritha.

TN Indication in Acute CVA

Ischemic CVA Ischemic CVA with BP <190/110 Ischemic CVA with hypotension- an ideal

treatment

TN can be used with Caution in

All Acute Hemorhagic CVA without headache, vomitting and siezure

Acute Hemorhagic CVA with BP <190/110 CVA with Bulbar Palsy Acute Ischemic or Hemorhagic CVA who is

comatose/stupor with Bulbar Palsy CVA ischemic with BP >190/110 and <220/120

TN is Contra indicated in Acute CVA in the following condns.

Hemorrhagic stroke with seizure, neck stiffness, headache and vomiting till stabilisation.

Hemorrhagic stroke with BP> 190/110 Massive hemorhagic stroke- 1st 2-4 days Large artery infarct with BP >220/120 CVA in a patient with h/o epilepsy. In Huge ischemic stroke, who is already under

anti coagulants with INR >3 IU or high doses of anti platelets.

TN Ingredients

Mode of Action of TN in Acute CVA- A hypothesis

Perfusion Immediately after administration of TN BP

raises to its peak up to 220-280/130-170 mm of Hg in most of the patients and gradually comes down to mid phase in 20-30 minutes and previous level in 1-6 hours depending upon the persistance of irritation, in some patients constantly maintained in high mid level for some hours.

Mode of Action of TN in Acute CVA- a hypothesis

Perfusion

This sudden hike in blood pressure helps in flushing of blood to the Penumbra area and also encourages fast collateral circulation to reach penumbra and can save the dying brain tissue.

Mode of Action of TN in Acute & Chronic CVA - A hypothesis

Neuroplasticity

Neuroplasticity is activation of the spared adjacent latent neurons which are capable of doing the functions of damaged cells. If such cells are viable action of TN is excellent.

Complications of TN

Hemorrhagic conversion of Ischemic stroke worsening of hemorrhagic stroke Increase in the Intracranial pressure which

may ultimately result in reduced perfusion. (Repeated intermittent administration must be avoided)

Possibility of development of aspiration pneumonia in comatose pts especially with Bulbar palsy.

Mode of Action of Irritant Lepas

Neuroplasticity by stimulating the CNS through nerve endings

Possibility of absorption of active lipid soluble molecules through skin having specific neuroprotective activity

Lepas

Saindhavadi Lepa- Saindhava, Grihadhooma and Gingelly Oil

Agni chikitsa Lepa

Pinda sweda

Oil massage with specific herbal oil which may also contain some specific neuroprotective molecules.

Massage and phomentation once again stimulates CNS through Nerve endings which encourages neuroplasticity.

Pindasweda Usually practiced

Shastikashali Pindasweda Masha Pindasweda

Others Pizichil Annalepana

Main oils used are

Mahamasha taila and Agni taila (prop)

Shirodhara

Which helps to subside anxiety, depression, and psychological symptoms which is very common in CVA

Also helps in gradual reduction of hypertension

Commonly practiced are Taila and Takra dhara

Basti

We also treat some patients with medicated enema if found essential

Accupuncture & Physiotherapy

Stimulates Nerve endings and helps in neuroplasticity

Rehabilitation through Physiotherapy. We use a special technique of inducing

pressure over pain points a variety of Marma therapy – Ayurveda physiotherapy.

Herbal medicines

Cholestonorm Capsule in ischemic stroke Main ingredients are garlic, Ajwain, Krishna

jeeraka, Saindhava lavana, Shunti, and Chandraprabha vati with additional shilajithu.

Main action as antiplatlet drug. Confirmed the action by observing the bleeding and clotting time. Also helpful in reducing Cholesterol and Triglyceride level.

Kwatha preparations

Mashathmagupthadi kwatha Balakulathadi kwatha Dhanadanayanadi kwatha Bala godhumadi kwatha Rasna sapthaka kwatha Bala jeerakadi kwatha etc

Considering the associated symptoms

Kapikachu and Ashwagandha churna

5g three times daily as a neuroprotective and to improve healing power.

Kapikachu alone - specially we use in cerebellar stroke with gait ataxia gives tremendous result. Dosage must be 15-25g per day in 3-5 divided doses.

Projeny M tablet

Improved version of Pusphadhanva Ras where we reduced the Naga bhasma to 1/10th and added with Jasada bhasma and trace of Swarna bhasma.

Improves healing ability of the tissues, and used as neuroprotective

Kshirabala Avarthitha

As a rejuvenative drug, and as anupana with Mashathmaguptha kwatha

Nasika Taila (prop)

TN can not be used for long time. Hence in chronic management, Nasya

which is not a Marsha nor Prathimarsha but with mid potency which can be used for long time without any complicaton, we use Nasika taila to encourage neuroplasticity.

Main ingredients are Kokilaksha beeja, Hingu and Gomuthra

Thank You